Why do people think CC will save anesthesia?

[DrRobert]

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I can. Unfortunately its a common scenerio and any CC trained doc should be able to handle this set of issues. My favorite is when they are also seizing from the toxins built up from their AKI. AKA uremic encephalopathy. I dont remember seeing one of those in the OR.

Hmmm. Private practice. 500+ bed hospital. Level 1 Trauma Center. 60 ICU beds. We (anesthesia) get called for ALL airways day or night, ALL a-lines day or night, and MOST central lines day or night. This is in spite of having 6 BC Pulmonology/CC docs. And FYI, doing these procedures is not in our contract... we do it as a "courtesy".

Needless to say, I'm pretty underwhelmed with the procedural skills of Pulm/CC docs.

 

[VentdependenT]

Sounds like a good gig for them actually. Would save me a TON of time if I had that setup. Why would they want to change that culture? Do you manage the patients or just put in the tubes/lines and then head back to the call room/or?

Dont you guys get to bill for that? If so id hardly call it a courtesy. If not then why not?

 

[DrRobert]

Sounds like a good gig for them actually. Would save me a TON of time if I had that setup. Why would they want to change that culture? Do you manage the patients or just put in the tubes/lines and then head back to the call room/or?

Dont you guys get to bill for that? If so id hardly call it a courtesy.

I think we get $50 per intubation, maybe $25 for an a-line.

We do not manage the patients... we do the procedure then walk away.

We do it because it's the right thing to do for the patient. I feel bad when we can't get a line, and the patient has high-dose Levo running through a 20g peripheral, and you just have to walk away knowing that the patient will never get a line... well maybe a PICC line the next day.

 

[VentdependenT]

sounds like a cultural issue. if you stopped doing those things your group would catch hell Id imagine. Sorry dude.

 

[redy]

Sounds like an institutional thing that where there is nobody inhouse other than the anesthetists. Otherwise I cannot imagine why the pulm/CC guys are not doing/hiring a PA to do the central and a-lines.

 

[BLADEMDA]

Sounds like a good gig for them actually. Would save me a TON of time if I had that setup. Why would they want to change that culture? Do you manage the patients or just put in the tubes/lines and then head back to the call room/or?

Dont you guys get to bill for that? If so id hardly call it a courtesy. If not then why not?

As good as you think you are after Fellowship those skills need to stay sharp. By avoiding the airways and lines most Pulm/CC guys become quite "dull" at procedures.

In this day and age if you can't do the required skills of your specialty then the hospital should find someone who can.

 

[deleted126335]

Now that is the real world right there brother. Amen.

In my world the ICU directors are pulmonologists who can't intubate and aren't even credentialed in central lines.

 

[VentdependenT]

well then i guess all CC dudes need is a procedure lackey....

 

[VentdependenT]

In my world the ICU directors are pulmonologists who can't intubate and aren't even credentialed in central lines.

sounds like a cutting edge critical care atmosphere where interprofessional respect is fostered.

 

[deleted126335]

sounds like a cutting edge critical care atmosphere where interprofessional respect is fostered.

You hit that one out of the park.

 

[ssmallz]

Cc won't save anesthesia, it only offer those w/credentials an alternate way to make money if the poop hits the fan for anesthesiologists.


My experience w ICU has been similar to others. ICU docs may know medicine but anesthesia becomes the procedure bitch when they can't (don't want) to come in and do lines. Can't tell you how many pts Ive had sent from the ICU on levophed through a 20g PIV w/no a line....almost as much fun as getting called at midnight to place a central line bc the intensivist doesn't want to come in

 

[deleted126335]

Cc won't save anesthesia, it only offer those w/credentials an alternate way to make money if the poop hits the fan for anesthesiologists.


My experience w ICU has been similar to others. ICU docs may know medicine but anesthesia becomes the procedure bitch when they can't (don't want) to come in and do lines. Can't tell you how many pts Ive had sent from the ICU on levophed through a 20g PIV w/no a line....almost as much fun as getting called at midnight to place a central line bc the intensivist doesn't want to come in

Are you one of my partners?

 

[ctsicu]

Well don't worry plenty of noctors will soon make themselves available for the pulm docs who are klutzy with their hands.

 

[infarct]

Agree with "should be able". How many ICUs, including community hospitals actually can provide this level of service 24/7?

i can...and i'm just a 2nd year IM resident.

 

[vector2]

Hmmm. Private practice. 500+ bed hospital. Level 1 Trauma Center. 60 ICU beds. We (anesthesia) get called for ALL airways day or night, ALL a-lines day or night, and MOST central lines day or night. This is in spite of having 6 BC Pulmonology/CC docs. And FYI, doing these procedures is not in our contract... we do it as a "courtesy".

Needless to say, I'm pretty underwhelmed with the procedural skills of Pulm/CC docs.

I'm also in a ~500 bed, ~60 ICU bed tertiary center and anesthesia definitely gets paged here for pretty much every non-er airway unless there just happens to be one of the senior pulm/cc fellows or occasional staff present who feels comfortable. Most of the IM-2's aren't certified on their lines yet (which is totally embarrassing since there enough lines available to get certified one or two weeks through your intern micu rotation as I did), so they're usually paging either the night float IM pgy3 resident or anesthesia or the sicu resident if there's a night icu admit. I think a large part of the problem is that the vast majority of IM and pulm/cc staff just don't do enough of these procedures to stay competent and the general unfamiliarity ends up trickling down to their fellows and residents...

 

[VentdependenT]

Again doing procedures doesnt make you an intensivist, its makes you a proceduralist. Until you start managing pts outside of the OR you will just be called on to perform this service. Keep slammin on the pulm dudes but step up and manage. The NP can do lines for us too so we dont have to come in. The vascular service doesnt bitch and moan when consulted in middle of night to line up pts for the group Im joining. Its professional. not a fugging bragging right.

 

[badasshairday]

Again doing procedures doesnt make you an intensivist, its makes you a proceduralist. Until you start managing pts outside of the OR you will just be called on to perform this service. Keep slammin on the pulm dudes but step up and manage. The NP can do lines for us too so we dont have to come in. The vascular service doesnt bitch and moan when consulted in middle of night to line up pts for the group Im joining. Its professional. not a fugging bragging right.

You guys have a surgeon or radiologist come in the middle of the night to do a line for your patients?

 

[ssmallz]

Again doing procedures doesnt make you an intensivist, its makes you a proceduralist. Until you start managing pts outside of the OR you will just be called on to perform this service. Keep slammin on the pulm dudes but step up and manage. The NP can do lines for us too so we dont have to come in. The vascular service doesnt bitch and moan when consulted in middle of night to line up pts for the group Im joining. Its professional. not a fugging bragging right.

I have no desire to "step up" and manage these pts. I don't have the desire or fund of knowledge necessary for this so I have all the respect in the world for the intesivists' skillet. With that being said I hate being a procedure bitch bc some doc is too lazy to do their procedures or doesn't know how. An intensivist IMO should know how to do basic ICU procedures (intubations, a lines, and central lines). If you can't/won't do them you don't deserve the salary you are making for covering the ICU. Seeing pts in septic shock on levophed with no a line or central access is laziness at best and negligence bordering on malpractice at worst.

 

[VentdependenT]

It sounds like you have some douche bags in house. Im not one of em. But when im covering 3 hospitals Q5 it helps me a ****load to not have to drive in to put in flippen lines in IF we have personell to do it for us at 2am.

 

[badasshairday]

It sounds like you have some douche bags in house. Im not one of em. But when im covering 3 hospitals Q5 it helps me a ****load to not have to drive in to put in flippen lines in IF we have personell to do it for us at 2am.

I'm at a community shop. Our Pulm/CC docs are very good. Open ICU. THey can consulted for post surgical patients, cardiac, neuro patients, and obviously the medical patients. They do subclavians, IJ's, intubate with ease, and walk newbie PGY1's through it all the time. If they are at home overnight, they will obviously come in if needed, but we have 24/7 hospitalist. They can do basic procdures. If a shocky patient is coming from the ED, they ER docs line and tube them so it isn't even a problem.

At our shop, radial arterial lines can be done by RT, we don't even have to dink around with those little procedures, which is especially nice when you are super busy. RT is in house 24/7. If they can't get radial the doc's do it (either radial or femorial or with ultrasound). Hell some of our RT's are very good at intubating.

I agree with those who say that the PROCEDURES DO NOT make the intensivist. You can train anyone to do basic ICU procdures. Let's be totally clear about that.

 

[Bostonredsox]

I'm at a community shop. Our Pulm/CC docs are very good. Open ICU. THey can consulted for post surgical patients, cardiac, neuro patients, and obviously the medical patients. They do subclavians, IJ's, intubate with ease, and walk newbie PGY1's through it all the time. If they are at home overnight, they will obviously come in if needed, but we have 24/7 hospitalist. They can do basic procdures. If a shocky patient is coming from the ED, they ER docs line and tube them so it isn't even a problem.

At our shop, radial arterial lines can be done by RT, we don't even have to dink around with those little procedures, which is especially nice when you are super busy. RT is in house 24/7. If they can't get radial the doc's do it (either radial or femorial or with ultrasound). Hell some of our RT's are very good at intubating.

I agree with those who say that the PROCEDURES DO NOT make the intensivist. You can train anyone to do basic ICU procdures. Let's be totally clear about that.

as evidence, I can do pretty much everyone of them in <6 minutes. And I can barely walk and breath at the same time. Procedures can be taught to monkeys, its the medicine that takes skill. It sounds to me like alot of the above posters are at shops which have allowed the pulm/cc guys to just be 'cerebralists' and not use their hands, (which is dumb to me as 2/3 the reason I love CC is the procedures). you guys need to put an end to that and stop doing them. They are capable of doing them themselves. Make a motion at your medical staff meetings about it. Or higher a bunch of hospitalists. We crank those procedures out like butta and we are always in house 24/7.

 

[deleted126335]

as evidence, I can do pretty much everyone of them in <6 minutes. And I can barely walk and breath at the same time. Procedures can be taught to monkeys, its the medicine that takes skill. It sounds to me like alot of the above posters are at shops which have allowed the pulm/cc guys to just be 'cerebralists' and not use their hands, (which is dumb to me as 2/3 the reason I love CC is the procedures). you guys need to put an end to that and stop doing them. They are capable of doing them themselves. Make a motion at your medical staff meetings about it. Or higher a bunch of hospitalists. We crank those procedures out like butta and we are always in house 24/7.

Agree that facility with procedures does not make an intensivist. I think that this skill necessary but not sufficient.

 

[VentdependenT]

You guys have a surgeon or radiologist come in the middle of the night to do a line for your patients?

They are in house in the night. I am not. No radiologist does this bull$hit at night. Waste of time and resources.

 

[slunk]

as evidence, I can do pretty much everyone of them in <6 minutes. And I can barely walk and breath at the same time. Procedures can be taught to monkeys, its the medicine that takes skill. It sounds to me like alot of the above posters are at shops which have allowed the pulm/cc guys to just be 'cerebralists' and not use their hands, (which is dumb to me as 2/3 the reason I love CC is the procedures). you guys need to put an end to that and stop doing them. They are capable of doing them themselves. Make a motion at your medical staff meetings about it. Or higher a bunch of hospitalists. We crank those procedures out like butta and we are always in house 24/7.

I wouldn't go that far. I've seen MICU guys not able to handle more than a few airways and lines when I was in training, with obvious medical consequences if there wasn't additional help.

Procedures take skill and that comes from years of repetition. Medical knowledge and experience comes along with that same time frame. A good physician needs all of it.

 

[VentdependenT]

Or a nurse. Or an RT...

 

[redy]

I have no desire to "step up" and manage these pts. I don't have the desire or fund of knowledge necessary for this so I have all the respect in the world for the intesivists' skillet. With that being said I hate being a procedure bitch bc some doc is too lazy to do their procedures or doesn't know how. An intensivist IMO should know how to do basic ICU procedures (intubations, a lines, and central lines). If you can't/won't do them you don't deserve the salary you are making for covering the ICU. Seeing pts in septic shock on levophed with no a line or central access is laziness at best and negligence bordering on malpractice at worst.

Agree 100%. I am IM going into pulm/CC. I hope to god I do not become like your intensivists. Its nothing more than laziness. Actually septic shock patients with no central line and on levophed is malpractice.

 

[countingdays]

Fried kidneys. .I got sign out from my day senior, I was the night guy, and it just didn't add up. I could tell it wasn't adding up to him too. Reading through the acidosis numbers and the story and such....something not right sounds like a psych case with an ingestion. I finish my evening round, go talk with the wife...hey is they're any chance he could have ingested any chemicals or anything unusual. She says no. About 10 min later nurse brings the wife back to me saying she has a question. "Sorry doctor I have just been thinking about this for a while, does antifreeze count as a toxic chemical.".... Yes it would mam Why do you ask?.....well I found him On the floor of the garage and there was a fluorescent green tinge in the corners of his mouth and an empty container next to him, to tell you the truth I me never thought much of it at the time"...... That will do mam thank you..turn to nurse..get me the oncall nephrologist and call ex to see if we have any fomepizole. Once I actually sat down to go over all his stuff he did have the classic osmolar gap of like 18.

The senior presented it as an M and M. Kind of a famous case amongst our very young IM program, which was in its first year at that time. He dialized daily for almost 2 months. Trached/PEGd, got VAP, long long complicated stay. I saw him in the Ed with his mom, another colossal train wreck who comes in septic routinely from the NH. he's about 130 pounds lighter now.

Sounds like he'd have been better off if you just left him alone.

Providing misguided, expensive, pain-increasing treatments to patients who should get only comfort care is the reason I could never do CC.

 

[RT2MD]

Sounds like he'd have been better off if you just left him alone.

Providing misguided, expensive, pain-increasing treatments to patients who should get only comfort care is the reason I could never do CC.

Very valid point. Anyone on here done a critical care and palliative care fellowship? Seems like the palliative fellowship could really help in the ICU... or maybe that's just me.

Edit - Good to see the Prince avatar back, hope things are going good with you Venty!

 

[Bostonredsox]

Sounds like he'd have been better off if you just left him alone.

Providing misguided, expensive, pain-increasing treatments to patients who should get only comfort care is the reason I could never do CC.

He is 55 and is alive? And functionally independent. And is no longer on HD nor does he have a trach. We saved his life. Am I missing something here??

 

[countingdays]

He is 55 and is alive? And functionally independent. And is no longer on HD nor does he have a trach. We saved his life. Am I missing something here??

Last thing I read was peg/trach/wt loss/dialysis.
I hope he's happy. He was suicidal before and his life probably isn't better so who knows?
At least he isn't a vegetable like many post-ICU pts.

Anyway my problem isn't with that one patient but the way CC drags out the miserable end of life and/or keeps organs going when the person is long gone. That was definitely my experience in the micu, less so in sicu and picu, and I couldn't stand it.

 

[VentdependenT]

Last thing I read was peg/trach/wt loss/dialysis.
I hope he's happy. He was suicidal before and his life probably isn't better so who knows?
At least he isn't a vegetable like many post-ICU pts.

Anyway my problem isn't with that one patient but the way CC drags out the miserable end of life and/or keeps organs going when the person is long gone. That was definitely my experience in the micu, less so in sicu and picu, and I couldn't stand it.

Until doctors are allowed to call all the shots with goals of care its all about working with families wishes. Why do you think there are so many Kindreds? People dont wanna let go. They hope for miracles.

Personally I start goals of care conversations early. I think 60-80% of all health care dollars are spent on the last 3 months of life. Crazy.

 

[Bostonredsox]

Until doctors are allowed to call all the shots with goals of care its all about working with families wishes. Why do you think there are so many Kindreds? People dont wanna let go. They hope for miracles.

Personally I start goals of care conversations early. I think 60-80% of all health care dollars are spent on the last 3 months of life. Crazy.

its actually close to 95% in the last 6 months of life per most recent govt data.

And I agree with Vent, until I can make a medical decision to withold care because of futility without legal ramifications, people will continue to get critical care they should not be receiving. I start the talks very early. But some people just are not rationale. Surgeons have the benefit of saying, this procedure will likely kill you and has little chance of bringing benefit thus I AM NOT doing it. I cant say that when it comes to tubing someone or performing general critical care. Not without them saying had you intubated them they would still be alive now. It doesnt matter what state 'alive' really means. We are not protected in this medical-legal society. And for this reason I will continue to do what I do.

 

[chessknt]

its actually close to 95% in the last 6 months of life per most recent govt data.

And I agree with Vent, until I can make a medical decision to withold care because of futility without legal ramifications, people will continue to get critical care they should not be receiving. I start the talks very early. But some people just are not rationale. Surgeons have the benefit of saying, this procedure will likely kill you and has little chance of bringing benefit thus I AM NOT doing it. I cant say that when it comes to tubing someone or performing general critical care. Not without them saying had you intubated them they would still be alive now. It doesnt matter what state 'alive' really means. We are not protected in this medical-legal society. And for this reason I will continue to do what I do.

Do you think that a single person should ever have that kind of authority (or liability)?

A reasonable idea for this would be an empowered interdisciplinary panel, not too dissimilar from the ethics consult teams, that would determine whether or not care was futile. There will always need to be forms of legal recourse for these things, but this would need to be in a fast-track environment with knowledgeable judges and no form of punishment beyond barring the mandatory withdrawal of care.

Getting this idea to be politically palatable is really the biggest hurdle that will likely never be cleared until it becomes absolutely necessary.

 

[VentdependenT]

Agreed.

Regardless the current state expedature is unsustainable and something will have to give way.

 

[countingdays]

Do you think that a single person should ever have that kind of authority (or liability)?

A reasonable idea for this would be an empowered interdisciplinary panel, not too dissimilar from the ethics consult teams, that would determine whether or not care was futile. There will always need to be forms of legal recourse for these things, but this would need to be in a fast-track environment with knowledgeable judges and no form of punishment beyond barring the mandatory withdrawal of care.

Getting this idea to be politically palatable is really the biggest hurdle that will likely never be cleared until it becomes absolutely necessary.

It's already absolutely necessary. The country is under crushing debt and the baby boomers are just getting started in taking way more than they ever put into the system.

If a panel determines futility of care, it needs to review all cases, not just those so terrible that they get referred. We have panels now, they just don't work. We may, and should, end up with those national death panels Sarah ****** Palin was so afraid of.

Also, family members shouldn't be asked to consent for procedures on dnr patients who are no longer competent. Some assault charges would probably put a stop to that practice.

 

[dotcb]

Very valid point. Anyone on here done a critical care and palliative care fellowship? Seems like the palliative fellowship could really help in the ICU... or maybe that's just me.

This person did:

http://palliative.emory.edu/about/team/majesko_alyssa.html

Gave a good interview on intersection of Pall Care w/ ICU care on the Icritical Care podcast # 189::

http://www.sccm.org/Publications/iCritical_Care/Pages/Podcast_Archive.aspx

 

[chessknt]

It's already absolutely necessary. The country is under crushing debt and the baby boomers are just getting started in taking way more than they ever put into the system.

If a panel determines futility of care, it needs to review all cases, not just those so terrible that they get referred. We have panels now, they just don't work. We may, and should, end up with those national death panels Sarah ****** Palin was so afraid of.

Also, family members shouldn't be asked to consent for procedures on dnr patients who are no longer competent. Some assault charges would probably put a stop to that practice.

You have confused a reasonable definition of necessary with a political one. In politics, something is only necessary to act on if the consequences of not acting are disastrous enough to get you thrown out of office or not reelected. With fat doctor salaries and evil insurance CEOs and diabolic drug companies to target, why inconvenience the most powerful voting bloc in the US?

 

[RT2MD]

Very valid point. Anyone on here done a critical care and palliative care fellowship? Seems like the palliative fellowship could really help in the ICU... or maybe that's just me.

This person did:

http://palliative.emory.edu/about/team/majesko_alyssa.html

Gave a good interview on intersection of Pall Care w/ ICU care on the Icritical Care podcast # 189::

http://www.sccm.org/Publications/iCritical_Care/Pages/Podcast_Archive.aspx

Awesome, thanks!

 

[gasattack3]

How many poor souls have we all seen in the ICU where the wife states "he never wanted this. we've talked about this while watching TV so many times".

Only to be alienated as the Grim Reaper by one or most family members. So, the wife caves, confused and frustrated, scared. And the dude "gets the full treatment" which is often futile. It's madness how we do things.

Too few have balls in medicine. Nobody wants to tell the family the real deal. Even most of the ICU docs, because of course surgeons generally hold out hope and give false hope IMHO. ICU docs don't want to rock the boat.

I think this is a major problem of open units. If more control went to the ICU docs, perhaps these conversations would occur earlier and a lot of suffering, and resources would be spared. The costly heroic s.hit we do to/for people in the last few hours (often) of life is f.cking insane and is going to further bankrupt our broken system.

On a separate note, I don't see CC "saving" anesthesia. Show me the jobs in PP for CC anes dudes. I hear rumors of them, but I'm not convinced.

 

[NRAI2001]

Actually not only we will not get Intensive care back... we are in the process of loosing pain medicine as we already lost pre-operative medicine.

Seems like to me every person/resident I see going into neurology these days plans to do something pain related..

 

[fakin' the funk]

How many poor souls have we all seen in the ICU where the wife states "he never wanted this. we've talked about this while watching TV so many times".

Only to be alienated as the Grim Reaper by one or most family members. So, the wife caves, confused and frustrated, scared. And the dude "gets the full treatment" which is often futile. It's madness how we do things.

Too few have balls in medicine. Nobody wants to tell the family the real deal. Even most of the ICU docs, because of course surgeons generally hold out hope and give false hope IMHO. ICU docs don't want to rock the boat.

I think this is a major problem of open units. If more control went to the ICU docs, perhaps these conversations would occur earlier and a lot of suffering, and resources would be spared. The costly heroic s.hit we do to/for people in the last few hours (often) of life is f.cking insane and is going to further bankrupt our broken system.

On a separate note, I don't see CC "saving" anesthesia. Show me the jobs in PP for CC anes dudes. I hear rumors of them, but I'm not convinced.

+1 FTW

The worst is seeing someone getting flogged who "never would have wanted this" but other family members are calling the shots once they're in the ICU. That honestly is the most depressing, saddest phenomenon I've experienced in medicine. Disrespecting and taking their loved one's dignity when they are circling the drain, against their wishes, usually for personal/selfish reasons. Sick.

 

[Silent Cool]

Seems like to me every person/resident I see going into neurology these days plans to do something pain related..

I have heard that other areas of Neuro have been cut, while pain still remains $$$. At the same time, however, I have also heard of some outstanding opportunities for gen'l Neuro (read: $$$) while I also hear that pain WILL be cut. So who knows?

 

[gasattack3]

+1 FTW

The worst is seeing someone getting flogged who "never would have wanted this" but other family members are calling the shots once they're in the ICU. That honestly is the most depressing, saddest phenomenon I've experienced in medicine. Disrespecting and taking their loved one's dignity when they are circling the drain, against their wishes, usually for personal/selfish reasons. Sick.

I've witnessed a dude tear up (while tubed) as "we" discuss putting yet another dialysis catheter into him. Never even wanted to be tubed in the first place, per wife "he never wanted this, we talked about it more than once"......

Surgeon's holding out hope to other family members, wife alienated, dude suffering more than anyone should, money thrown out the window like it's funny money (it is at this point).
ICU people in our unit toeing the line not to upset the cardiac surgeon who doesn't want this guy dying on his 30 day watch.... Terrible.

Wife feels like the Grim Reaper so she o.k.'s things she normally wouldn't and doesn't feel good about, but does feel guilty for NOT allowing..... Dies anyway of course.